Update as Noticed in late 2013

In Alabama, all of our claims in 2013 have automatically stopped paying out to the patient after 12 visits.  This seems to be the case regardless of  changing the date of incident.  They used to do this, but were stopped.  It is quite clear that the system is designed to stop the payout at 12 even though there is not supposed to be any limitation of care. 

We will be handling this to the point that unless the new date of incident is backed up by a significant event, we cannot file the claim with an expectation of reimbursement or the visits require the patient to elect  Option 2.  Otherwise, we cannot see the patient after 12 visits in most all cases.    Most visits after 12 will be converted to maintenance care.  Expect no reimbursement after 12 visits.
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Medicare Office Policy

We have one of the best facilities providing excellent care to help senior and elderly patients. Instrument adjustment is the most safe technique for any older patients and/or patients having had surgeries.  Unfortunately, Medicare cannot be expected to resolve the costs of truly getting better.  Costs for treating extremity joint dysfunction (knees, shoulders, etc.) and its accompanying pain are not covered in any fashion, and yet we could help with these very common senior complaints.

LIMITATIONS OF CARE

Crafton Chiropractic has Medicare patients.  We accept these patients upon the recommendation from a friend or family member who is our current patient.  Always, however, the Medicare patient has been misinformed or made no inquiry into how Medicare works for chiropractic.   Medicare greatly restricts chiropractic benefits.  They will pay for only one spinal adjustment code.  The fee for this code is guaranteed to be the lowest fee for this procedure; therefore, they do not reimburse for a complete treatment session.  These other necessary procedures are the patient's financial responsibility.  These non-covered procedures include the examination, x rays, and any adjunctive therapies.  This is an outrageous inequity designed to purposely exclude chiropractors from helping the nation's seniors. These are necessary for analysis, safety, and efficiacy of care and the therapies are essential supportive care that they willingly pay to other health care physicians and therapists; however, bottomline, they are not covered by Medicare for chiropractors, nor are they covered by SUPPLEMENTARY POLICIES including the most popular, AARP, C+, Humana, and Blue Advantage.

FOR REASONS OF SAFETY AND EFFICACY AND TO PROTECT OUR PROFESSIONAL STATUS, WE WILL NOT TREAT A PATIENT WITHOUT HAVING A FULL SET OF X RAYS TAKEN IN OUR OFFICE OR TO OUR SPECIFICATIONS AND ALSO BE GIVEN THE OPPORTUNITY TO EXAMINE THE PATIENT.

TO DO SO FOR FREE WOULD BE CONSIDERED A VIOLATION OF LAWS GOVERNING MEDICARE PARTICIPATION.

We are able to bill for Medicare for this one procedure, but we have elected a NON PARTICIPATORY status with Medicare and are approved to send in paper claims.  This is because we have a very limited caseload of patients.  Paper claims take longer and the patient is always forewarned that bills can accrue faster than we are informed that they are to be rejected.  Also if accepted, you have to expect that you could have a sum of money being held up by Medicare before you are reimbursed.

NON PARTICIPATORY status means that you still have the benefits but you are required to pay for your services in our office.  We submit the paper claims to Medicare, and you have to wait for reimbursement.  We will ACCEPT ASSIGNMENT and wait for reimbursement only if you have a viable SECONDARY BLUE CROSS BLUE SHIELD policy that is eligible for covering procedures that Medicare does not cover.  In this case, we wait for reimbursement from Medicare and bill you later for what is unpaid by both Medicare and Blue Cross.

Since we are in network with BCBS, we must accept assignment for Blue Advantage for Medicare, but Blue Advantage also only pays for the one adjustment code.  Here you have a co-pay requirement for each visit which actually pays for most of the bill.  Medicare has a deductible and most BCBS policies have deductibles. 

In all cases, we would hope that you manage the remittances you receive from all carriers as they are usually the final determination of the claim and they do spell out who has been paid and how much is owed the provider.

PLAN OF CARE

Medicare pays for adjustment codes with the expectation that all claims are part of a Plan of Care being followed by the patient.  They do not pay for maintenance care.  They can and often do require us to document and prove the medical necessity for the care and that the patient is following a Plan of Care related to a date of incident.  We have elected to define the distinction between Plan of Care and Maintenance Care, and as a condition for receiving care we ask for your cooperation, so we can comply with this Federally reviewed program.

Unfortunately, not all chiropractic physicians follow these requirements making it appear that the Medicare patient can see the physician whenever they choose to come in for free.  We are unwilling to do this and have the option to not accept that patient.  Any paid claim could be later examined by Medicare to determine whether it qualified for the payment that was made whether it went directly to the provider or the patient, so it is imperative that these guidelines are followed if you elect to use Medicare.

NEW
FOR 2012     Fortunately, the new 2012 ABN form (See FORMS) offers the patient the option to receive care under any conditions that they deem appropriate from the chiropractor as long as they sign the form agreeing that a claim is not to be filed.  So if we believe that you are not following the Plan of Care or that you do not want to follow one, we could still elect to treat you.  You are still able to pay for the adjustment at a reduced rate, but you will not receive any reimbursement since no claim can be filed by either of us.  Remember that your reimbursement would not be as much as most people with excellent coverage pay as a copay.   This signed authorization is kept on file. 

These restrictive conditions apply in all cases with any patient who has Medicare status to include some Humana and Blue Advantage wher Medicare is not billed directly.  Any time Medicare determines that the procedures were not part of a Plan of Care or that the patient did not follow one, they can require the provider to refund Medicare and/or fine the provider.  This is why we must we strictly adhering to these guidelines.

Our definition of Plan of Care is a series of closely pre-scheduled visits where procedures are performed in accordance to a physician designed plan with the expectation to resolve the patient complaint to reach maximum benefit considering any limiting pre existing conditions, that upon completion would require an evaluation to determine any rationale to continue care with a new plan or to be released or referred out.

Regarding Medicare, they expect this and have always expected this compliance.  They want to see a re-evaluation, which they will not pay for, after the 12th visit and/or a new date of incidence.  They demand from the provider all the necessary reports and documentation to support compliance.   They are always the final word, so there is no third party arbitrary recourse.  They do not reimburse for a chronic condition that in itself cannot be altered. All diagnoses must indicate pain and/or limited function as a rationale to continue treatment at any phase in the plan.  Maintenance Care equals Occasional Care.  They only pay for a physician directed program.

OFFICE GUIDELINES FOR THE PLAN OF CARE

1. DID YOU MAKE AN APPOINTMENT THAT WEEK OR THE NEXT WEEK FOR YOUR NEXT VISIT?

2. DID YOU SEE THE DOCTOR FOR 12 VISITS WITHIN A RELATIVELY SHORT PERIOD OF TIME SUCH AS 2 MONTHS?

3. DID YOU AGREE TO FOLLOW ALL PROCEDURES DIRECTED BY THE PHYSICIAN? WERE YOU ABLE TO MAKE THE NECESSARY FINANCIAL ARRANGEMENTS TO FOLLOW THESE RECOMMENDATIONS?

4. DID YOU PROVIDE A DATE OF INCIDENT AND A QUALIFYING REASON FOR RECEIVING CARE?  UPON EACH VISIT DID YOU SIGN AND DESCRIBE THE DEGREE OF LIMITATIONS AND PAIN YOU ARE EXPERIENCING?

5. ONE VISIT FOR ONE INCIDENT IS MAINTENANCE CARE. NO ONE COULD REASONABLY CONSIDER THIS TO BE FOLLOWING A PLAN OF CARE.

6. ALL PLANS HAVE A BEGINNING, MIDDLE, AND END.  THEY TELL A STORY TO THE CARRIER THAT MAKES SENSE AND JUSTIFIES PAYMENT.

DR. CRAFTON'S OVERVIEW OF MEDICARE

"This Federal program and its bureaucratic empire is out to save money, make money from fines, intimidate, complicate and confuse, strain the physician and patient relationship, and thereby limit care just like any other insurance company or similar Federal program, but in this case, they monopolize the market, scapegoat for their own mismanagement, tax all people to pay primarily for themselves and restrict freedom of choice."

"Chiropractors, primary care physicians of equal status by definition in every state of the union, have been working to receive full equity in Medicare and other Federally funded programs, programs paid for by the all American taxpayers, but I do not expect any significant changes, even though statistical government funded research overwhelmingly shows a significant financial savings with improved patient outcomes.  Medicare is still "Medi" or "Medical only" care.  Chiropractors who elect to see you, do so only at risk with a great amount of internal management costs for only a fraction of their overhead costs.  They do so out of their pocket because they care about you, value your profession, and hope that someday they will be able to truly change the way we provide care to our seniors."

"If you are the type of Medicare patient who believes that the Medicare system is a blessing, that drugs are necessary, that everything provided by a physician must be free, quick, expressed, and fast, and that you really do not want to play an active role in improving your health,  please do not come here expecting our office to be designed around this Medicare model."

"I truly hope that I will still be able to help you as I do other seniors.  Thank you in advance for giving me this opportunity."

"

                         Dr. Katherine Crafton

UPDATE ON MEDICARE



Medicare has been announcing that providers can expect to receive from 32% TO 27% less per procedure beginning from January 2013.  This will have less of a dramatic effect on chiropractic because only one procedure is covered anyway; however, it will have a major effect on what medical providers will continue to accept Medicare patients.  One of our patients who happens to be an attorney was told by his occasional medical physician that he will be unable to see anyone over 85 in accordance to the new limitations being imposed by the government on care of the elderly.  It will be a wake up call when free care and limitless drugs meet no care and hospice that people will realize when its too late how they are valued.   When Sol, one of the last to remember when things were different, in the futuristic novel, Soylent Green, realized that its just better to be compliant and check out at the local  recycling center.  In the movie version, Sol was played by Edgar G. Robinson in one of his last if not his last movie role.  The newer generations do not understand these things; you should because many of you know history.  The newer governing generations do not respect the past and are very self serving.

I hope that you understand that as I have discovered over the years that when you no longer are contributing to the government or even your union's income base by being a regular income producer with funds taken out of your check, you are no longer valued and are considered a liability.   They are being clever and resourceful by recycling you into a consumer of drugs that are paid for by the income producers.  Many protected industries are dependent upon this guaranteed income.  This started in the 1960's when we were originally sold Medicare.   Chiropractors were never part of this system; we are not one of them.

Things are changing or coming to fruition.  Regarding our part in this system, we will be less likely to take Medicare cases unless the patient elects Option 2, paying the provider a reduced rate for care without expecting any reimbursement from Medicare which will only be around $12-$18 per visit,  or the patient elects to pay for necessary supportive therapies, since payment from only the one procedure cannot cover our costs.  In any case, to receive services for Medicare patients beginning 2013, all Medicare patients can expect to be paying out more money and receive less reimbursement from Medicare.  In 2013, we cannot have our minimum fee go below $50.00 per visit for only maintenance elective care when having to see the physician.  This new change  includes all Advantage, Humana, C+. and AARP programs no matter who is primary.   This new reduced fee will be reflected in Blue Advantage and Humana.  For the most part, I will continue to see Medicare patients in 2013 if they elect to pay $50.00 per visit. where in the last seven years we had been only been collecting $34.00 from Medicare patients and netting only $18-$24.00 per visit.  All of our costs have gone up dramatically; this new announcement from Medicare makes it a better time for us to make this change.